Provider Demographics
NPI:1548611569
Name:DERMA PLLC
Entity Type:Organization
Organization Name:DERMA PLLC
Other - Org Name:DERMA MEDICAL SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPA DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-350-5321
Mailing Address - Street 1:3025 LIMITED LN NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3025 LIMITED LN NW
Practice Address - Street 2:SUITE 100
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-2613
Practice Address - Country:US
Practice Address - Phone:360-350-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare